California Form Aap 2 – Fill Out and Use This PDF

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Adoption Finalization Date:

Date initial AAP Agreement (AD 4320) was signed:

This is a: (Check applicable items) Please send Notice of Action for the following checked items.

■

New case; Form AAP 4, Eligibility Certification - Adoption Assistance Program

■ Change in amount or duration of payment due to:

is attached, please send Notice of Action.

(Check (✔) one)

■ Denial, please send Notice of Action.

■

Completed reassessment.

■ Change in need or circumstances.

■ Deferred payment agreement, please send Notice of Action.

■

Case Terminated.

■ Change in child’s name, payee name or address.

■

Benefit Extension

■

Overpayment requiring collection.

■ Child/youth has a mental or physical disability

■ Child/youth meets one of the five participation

Reason for the denial, termination or overpayment to be stated on the Notice of Action:

criteria per Welfare and Institutions Code

Section 11403(b)(1) through (5)

Please start or change payments as follows:

Total monthly payment amount: ■ $

or ■ No cash payment, Medi-Cal only

The following checked rate structure equals the total monthly payment amount:

■

AAP Basic Rate: $

■

Specialized Care Increment: $

■

Dual Agency Rate: $

■

Supplemental Rate: $

■ Rate Classification Level (RCL):

■ State Approved Facility Rate: $

Start date:

Date of Reassessment:

$

to be paid to the facility

$

to be paid to the adoptive parent

$

to be paid to the Wraparound provider

$

to be paid to the adoptive parent

PAYEE NAME

SIGNATURE OF AUTHORIZED OFFICIAL OF ADOPTION AGENCY

▲

PAYEE ADDRESS

(NO.)

(STREET)

ADOPTION AGENCY MAILING ADDRESS

(CITY)

(STATE)

(ZIP)

PAYEE TELEPHONE NUMBER

TELEPHONE NUMBER

DATE

PAYEE EMAIL ADDRESS